What is the recommended workup and treatment for retained products of conception?

Management of Retained Products of Conception (RPOC)

Hysteroscopic removal under direct visualization is the recommended first-line management for retained products of conception to reduce risks of hemorrhage, infection, and future fertility complications. 1

Diagnostic Workup

Clinical Assessment

• Evaluate for symptoms including:
  • Vaginal bleeding
  • Pelvic pain
  • Fever (though often absent)

Imaging

• Ultrasound is the primary diagnostic modality with the following findings suggestive of RPOC:

  • Endometrial mass or focal endometrial thickening
  • Endometrial thickness >10mm (high positive predictive value) 1
  • Presence of vascularity on Doppler imaging within the endometrial abnormality 1
  • Enhanced myometrial vascularity 1
  • Heterogeneous or hyperechoic material within the endometrial cavity 2

• Point-of-care ultrasound (POCUS) can be used with high specificity (93.8%) but lower sensitivity (79.0%) 2

Caution: Reliance solely on ultrasound has a high false-positive rate (34% overall, 28.9% post-abortion, 51.5% post-delivery) 3, so clinical correlation is essential.

Treatment Algorithm

First-Line Management

• Hysteroscopic removal under direct visualization 1
  • Preferred over blind procedures like dilation and curettage (D&C)
  • Lower risk of intrauterine adhesions
  • Better for fertility preservation

Alternative Management Options

1. Medical Management (for hemodynamically stable patients without infection)

   • Vaginal misoprostol
   • Success rates vary (65% overall):
     • 76% if primary miscarriage management was expectant
     • 44% if primary management was medical
     • 40% if primary management was surgical 4

2. Office Aspiration with Karman Cannula

   • For suitable cases with confirmed RPOC on Doppler ultrasound
   • Lower success rates than surgical management 1

3. Dilation and Curettage (D&C)

   • When other methods fail or are contraindicated
   • Carries higher risk of intrauterine synechiae and fertility issues 4

4. Expectant Management

   • May be appropriate in select cases
   • Requires close follow-up

Special Considerations

High-Risk Patients

• History of cesarean delivery or uterine surgery
  • Higher risk of placenta accreta spectrum disorders 5, 1
  • May require more careful surgical planning

Timing of Intervention

• Optimal timing: within 5 weeks postpartum/post-abortion 1
• Delayed intervention increases risk of adhesion formation

Complications to Monitor

Immediate Complications

• Persistent vaginal bleeding
• Infection and endometritis
• Pelvic pain 1

Long-term Complications

• Intrauterine adhesion formation
• Subfertility/infertility
• Menstrual disturbances
• Increased risk of abnormal placentation in future pregnancies 1
• Arteriovenous malformation/fistula (rare complication, especially with history of sharp curettage) 1

Follow-up

• Post-procedure ultrasound to confirm complete removal of RPOC
• Clinical follow-up to ensure resolution of symptoms 1
• Consider hysteroscopy 2-3 months after treatment to assess for intrauterine adhesions if fertility is desired 1

Important Pitfall: Highly vascular RPOC can be mistaken for uterine arteriovenous malformation. Other diagnostic pitfalls include true arteriovenous malformations, invasive moles, blood clots, and subinvolution of the placental implantation site 6.